Retinal periphlebitis resembling frosted branch angiitis with nonperfused central retinal vein occlusion

Frosted Branch Angiitis; Case Series and Literature Review

PURPOSE

Frosted branch angiitis (FBA) is a rare form of retinal vasculitis. Four case series and an extensive literature review of 236 cases were conducted to clarify the characteristics of this rare condition.

METHODS

Case series and literature review.

RESULTS

An analysis of the reported cases revealed that a majority (54.6%) developed FBA in the presence of an underlying disease, with recurrence and complications requiring surgical intervention being rare. The frequency of bilateral occurrence (55.0%) and prevalence in female patients (45.0%) were noted to be lower than previously reported.

CONCLUSION

In general, idiopathic FBAs are more likely to be bilateral and diagnosed at a younger age than secondary FBAs. In idiopathic FBA, fundus involvement is more generalized, exudates tend to be more translucent, and extensive retinal hemorrhage tends to be less frequent. However, there were no differential characteristic fundus features that clearly distinguished idiopathic FBA from secondary FBA.

Combined central retinal vein occlusion and cilioretinal artery occlusion as the initial presentation of frosted branch angiitis: a case report and literature review

PURPOSE

To report a case of combined central retinal vein occlusion (CRVO) with cilioretinal artery occlusion (CLRAO) that heralded the development of frosted branch angiitis (FBA).

CASE REPORT

A 25-year-old healthy male presented with sudden painless visual loss in his left eye with a visual acuity (VA) of 20/300. Fundus exam and fluorescein angiography showed signs of combined CRVO and CLRAO. Without treatment, his vision gradually improved until it reached 20/30 within four months. Five months after initial presentation, he returned with severe visual loss (20/400) in the same eye and a clinical picture of severe occlusive periphlebitis resembling a frosted branch angiitis pattern associated with severe macular edema. This was promptly and successfully treated with systemic steroids and immunosuppressive medications.

CONCLUSION

CRVO in young population can have an unusual course and one should carefully rule out underlying uveitic etiologies in each visit. Clinical suspicion and close follow‑up are required for early detection and timely management of FBA.

Retinal periphlebitis associated with branch retinal vein occlusion and complicated by subfoveal hemorrhage: a case report

Retinal periphlebitis is a subtype of retinal vasculitis affecting the retinal veins. We report a case of bilateral branch retinal vein occlusion (BRVO) associated with idiopathic retinal periphlebitis and complicated by subfoveal hemorrhage (SFH). An 18-year-old woman presented with best-corrected visual acuity of 20/20 in the right eye and 20/30 in the left eye. Examination revealed bilateral retinal vascular sheathing predominantly involving the retinal veins and bilateral BRVO. Fundus fluorescein angiography revealed localized vascular leakage in the right eye and diffuse vascular leakage in the left eye. Spectral-domain optical coherence tomography showed mild nasal thickening with subfoveal fluid in the left eye. Oral steroids were started on a tapering dosage as well as oral methotrexate. A year later, she presented with regressed vascular sheathing in both eyes with 5/200 vision and SFH in the left eye. Pars plana vitrectomy, subretinal tissue plasminogen activator, intravitreal ranibizumab, laser photocoagulation, and gas injection were performed. The SFH resolved and the visual acuity improved to 20/100. Good vision was preserved in both eyes with no active inflammation. Timely management of SFH in idiopathic retinal periphlebitis can achieve a favorable visual outcome.

The main aspects of retinal vein occlusion etiopathogenisis in young adults. Part I. Neuroretinovasculitis (prothrombotic potential, clinical manifestations)

This review is dedicated to the neuroretinovasculitis, which is the leading cause of retinal vein occlusion in young adults. Presumed etiological factors, possible pathogenic mechanisms, and clinical manifestation are analyzed. Advisability of multidisciplinary approach in management and individual approach in treatment of patients with neuroretinovasculitis with secondary retinal vein occlusion are justified.

Central Retinal Vein Occlusion-like Appearance: A Precursor Stage in Evolution of Frosted Branch Angiitis

PURPOSE

To report a young man with a central retinal vein occlusion (CRVO)-like appearance which later evolved to frosted branch angiitis (FBA).

CASE REPORT

As 28-year-old Indian man presented with optic disc swelling, hyperemia, peripapillary hemorrhages, and dilated tortuous veins in the left eye, 6 months after being diagnosed with idiopathic FBA in the right eye. Within 3 days of presentation, the left eye developed FBA, which was promptly and successfully treated with oral steroids.

CONCLUSION

A CRVO-like picture may be the first stage of FBA. Young patients with CRVO and intraocular inflammation should be followed closely for early detection of FBA. Early initiation of oral steroids may preserve visual acuity in such cases.

Bilateral frosted branch angiitis as the presenting sign of antiphospholipid antibody syndrome

Background

“Frosted branch retinal angiitis” is an encompassing term for a rare, typically bilateral diffuse retinal periphlebitis that may occur in a number of varying conditions. To our knowledge, we report the first case of frosted branch angiitis as the presenting sign of antiphospholipid antibody syndrome in a 28-year-old woman.

Findings

This study is a retrospective case report and literature review. Serial fundus photos, fluorescein angiogram, and ocular coherence tomography taken were before and after treatment, showing resolution of diffuse retinal perivascular sheathing and macular edema along with marked improvement in visual acuity 4 months after the treatment with corticosteroids.

Conclusions

Frosted branch angiitis can be seen in association with antiphospholipid antibody syndrome. Prompt recognition and treatment with corticosteroids may result in good visual prognosis, and long-term immunosuppression and additional anticoagulation may be beneficial to prevent recurrence.

LONG-TERM EFFICACY OF SYSTEMIC INFLIXIMAB IN RECALCITRANT RETINAL VASCULITIS

PURPOSE

To evaluate the efficacy of systemic infliximab for the induction of remission in patients with retinal vasculitis, inadequately responsive to other immunomodulatory therapy, based on fluorescein angiography grading for retinal vasculitis evaluation.

METHODS

We analyzed 60 patients with retinal vasculitis, from the Massachusetts Eye Research and Surgery Institution in Cambridge, MA. Response to therapy was based on analysis of serial fluorescein angiography and fundus photography, including a baseline angiogram before initiation of infliximab.

RESULTS

Sixty patients received infliximab therapy between July 2007 and July 2012 at Massachusetts Eye Research and Surgery Institution for a diagnosis of retinal vasculitis. All had previously showed a poor clinical response to other immunomodulatory regimens, or ceased therapy due to intolerable side effects. The initial dose of infliximab was 5 mg/kg in all patients and remained at this dose for the extent of treatment in 57 (95%) patients. At 6 months, 45 of 51 (88.23%) patients were maintaining remission with therapy, 5 (9.8%) were in partial remission, and 1 patient had failed. At 12 months, 39 of 39 (100%) patients were maintaining remission with therapy.

CONCLUSION

Infliximab is effective for the treatment of recalcitrant noninfectious retinal vasculitis, refractory to conventional immunomodulatory therapy.

The course of retinal vasculitis

AIMS

To determine if characteristics of retinal vasculitis correlate with ocular complications, or the response to different lines of treatment.

MATERIALS AND METHODS

We performed a computerised database analysis of 56 patients evaluated for uveitis at the Casey Eye Institute from September 1985 until May 2010. All patients had non-infectious retinal vasculitis and at least 1 year of follow-up.

RESULTS

Although occlusive vasculitis was rare, retinal neovascularisation occurred much more commonly in the occlusive vasculitis subgroup than among the non-occlusive vasculitis subgroup (p<0.01). Epiretinal membrane (ERM) was found more commonly in the retinal vasculitis patients who presented with cotton wool spots and intraretinal haemorrhage compared to retinal vasculitis patients who presented with sheathing noted on clinical examination (p<0.01). Smoking was significantly related to vision loss. Age at presentation below 40 years correlated with therapy beyond oral corticosteroids

CONCLUSIONS

The heterogeneity of retinal vasculitis should be considered in providing prognostic information. Neovascularisation occurs more commonly in occlusive retinal vasculitis, and ERM is diagnosed more frequently in conjunction with cotton wool spots and intraretinal haemorrhage rather than just vascular sheathing. Cigarette use predicts visual loss and patients who are relatively young often receive treatment beyond oral corticosteroids.

Clinical Features of Central Retinal Vein Occlusion With Inflammatory Etiology

PURPOSE

The purpose of this study was to characterize central retinal vein occlusion (CRVO) with inflammatory etiology.

DESIGN

A retrospective study.

METHODS

We retrospectively reviewed 51 eyes of 48 patients with CRVO between 2004 and 2009 and investigated whether they had inflammatory findings related to retinal vasculitis, that is, severe peripheral retinal vascular changes based on fluorescein angiography and anterior vitreous cells. The extent of vascular leakage was classified as "mild," "moderate," and "severe" in angiographic images.

RESULTS

Six eyes of 5 patients (11.8%) had both inflammatory criteria. All patients were male and with a diagnosis of ischemic CRVO. No causative etiology was detected in any patient. The mean age was 46.4 (SD, 23.3) years. The age range was not limited to young generation. These patients received systemic corticosteroid therapy with a mean follow-up period of 41.8 months. The mean logMAR visual acuity [1.29 (SD, 0.77)] and central retinal thickness [1290.5 (SD, 399.0) μm)] at the initial visit were significantly (P = 0.004 and P = 0.001) improved at the final visit [0.94 (SD, 0.69) and 266.7 (SD, 135.4) μm, respectively].

CONCLUSIONS

Central retinal vein occlusion with idiopathic inflammatory conditions appears to have clinical characteristics of broad age range and good response to systemic corticosteroid therapy.

Differential diagnosis of retinal vasculitis

Retinal vaculitis is a sight-threatening inflammatory eye condition that involves the retinal vessels. Detection of retinal vasculitis is made clinically, and confirmed with the help of fundus fluorescein angiography. Active vascular disease is characterized by exudates around retinal vessels resulting in white sheathing or cuffing of the affected vessels. In this review, a practical approach to the diagnosis of retinal vasculitis is discussed based on ophthalmoscopic and fundus fluorescein angiographic findings.

Retinal Vasculitis

Retinal vasculitis is a sight-threatening intraocular inflammation affecting the retinal vessels. It may occur as an isolated ocular condition, as a manifestation of infectious or neoplastic disorders, or in association with a systemic inflammatory disease. The search for an underlying etiology should be approached in a multidisciplinary fashion based on a thorough history, review of systems, physical examination, and laboratory evaluation. Discrimination between infectious and noninfectious etiologies of retinal vasculitis is important because their treatment is different. This review is based on recently published articles on retinal vasculitis and deals with its clinical diagnosis, its link with systemic diseases, and its laboratory investigation.